Driving among patients with epilepsy in West China

Driving status and attitudes of patients with epilepsy holding a driving license in eastern China

PURPOSE

Patients with epilepsy (PWE) remain completely and permanently banned from driving under the latest changes to China's laws. The twoaims of this study were, firstly, to evaluate the driving status of PWE with a driving license and the determinants of them continuing to drive; secondly, to investigate awareness and perceptions of epilepsy driving restrictions among PWE and the general population.

METHODS

Patients with epilepsy with a driver's license who attended the Fourth Affiliated Hospital and the Second Affiliated Hospital of Zhejiang University for treatment of their condition were invited to participate in a questionnaire survey between June 2021 and June 2022. During the same period, age-matched people with driver's licenses without epilepsy living in the cities of Hangzhou and Yiwu, Zhejiang province were invited to participate in the questionnaire study.

RESULTS

A total of 291 PWE with a driver's license and 289 age-matcheddrivers among the general public participated in the survey. Of the sample, 41.6% of PWE and 26.0% of general drivers stated that they were aware of legal driving restrictions for PWE in China. In the past year, 54% of PWE had driven and 42.5% drove a vehicle daily. Logistic regression revealed that male sex (95% confidence interval [CI]: 1.36-3.61, P = 0.001), age (95% CI: 1.12-3.27, P ≤ 0.036), and the number of antiseizure medications taken (95% CI: 0.24-0.25, P ≤ 0.001) were independently associated with illegally driving with epilepsy. In terms of legalissues, 71.1% of PWE did not support a lifetime ban on driving and 50.2% disagreedwith physician reporting of PWE to the traffic authorities.

CONCLUSION

Illegal driving is highly prevalent among PWE who hold a driving license, and male gender, age, and number of ASMs had an independent association with illegal driving in patients with epilepsy. There are highly varying opinions on the current driving laws with respect to PWE. Detailed national standards for medical fitness for driving that are easy to implement and enforce are urgently required for China.

Juvenile Myoclonic Epilepsy: Seizure and Social Outcomes in Taiwan

Patients with juvenile myoclonic epilepsy (JME) may not achieve seizure freedom despite optimal treatment with antiseizure medications (ASMs). The aim of this study was to investigate the clinical and social features of patients with JME, and to determine the factors associated with outcomes. We retrospectively identified 49 patients with JME (25 females, mean age 27.6 ± 8.9 years) who were assessed at the Epilepsy Centre of Linkou Chang Gung Memorial Hospital in Taiwan. The patients were divided into two groups, those who were seizure-free and those with ongoing seizures according to their seizure outcome at the last follow-up for one year. Clinical features and social status were compared between these two groups. Twenty-four (49%) of the JME patients were seizure-free for at least one year, while 51% continued to experience seizures despite being treated with multiple ASMs. The presence of epileptiform discharges in the last electroencephalogram and seizures during sleep were significantly associated with worse seizure outcomes (p < 0.05). The patients who were seizure-free had a higher employment rate compared to those who continued to experience seizures (75% vs. 32%, p = 0.004). Despite receiving ASM treatment, a considerable proportion of the patients with JME continued to have seizures. Moreover, poor seizure control was associated with a lower employment rate, which may lead to negative socioeconomic consequences related to JME.

Unruptured brain arteriovenous malformations causing seizures localize to one common brain network

Seizures are a frequent symptom of unruptured brain arteriovenous malformations (bAVMs). However, the brain regions responsible for these seizures remain unclear. To identify the brain regions causally involved in bAVM-related seizures, we retrospectively reviewed 220 patients with unruptured bAVMs. Using voxel-based lesion-symptom mapping (VLSM) analyses, we tested whether individual brain regions were associated with unruptured bAVM-related seizures. The result revealed that unruptured bAVMs causing seizures are anatomically heterogeneous at the voxel level. Subsequently, lesion network mapping (LNM) analyses was performed to determine whether bAVMs causing seizures belonged to a distributed brain network. LNM analyses indicated that these lesions were located in a functional network characterized by connectivity to the left caudate and precuneus. Moreover, the discrimination performance of the identified seizure network was evaluated in discovery set by calculating the individualized network damage score and was tested in validation set. Based on the calculated network damage scores, patients were divided into low-, medium-, and high-risk groups. The prevalence of seizures significantly differed among the three risk categories in both discovery (p = .003) and validation set (p = .004). Finally, we calculated the percentage of voxels in the canonical resting-state networks that overlapped with the seizure-susceptible brain regions to investigate the involvement of resting-state networks. With an involvement percentage over 50%, the frontoparietal control (82.9%), limbic function (76.7%), and default mode network (69.3%) were considered to be impacted in bAVM-related seizures. Our study identified the seizure-susceptible brain regions for unruptured bAVMs, which could be a plausible neuroimaging biomarker in predicting possible seizures.

Individual prediction of motor vehicle accidents for patients with epilepsy

The objective of the study was to design a clinically useful tool to predict the risk of seizure-related motor vehicle accidents (MVAs) for people with epilepsy (PWE). Participants were patients who visited our epilepsy center in West China Hospital from October 2012 to October 2019 and were divided into a primary cohort and a validation cohort. Ultimately, we included 525 patients in the primary cohort and 86 patients in the validation cohort. Proportional hazard regression was performed to measure the prognostic factors of car accidents. The outcome was used to create a nomogram model. The final model had 7 factors, with a C-index of 0.85 (95% CI, 0.80-0.91), to predict the possibility of non-MVA for PWE. For the validation cohort, the C-index was 0.83 (95% CI, 0.72-0.95). This nomogram model can offer more individualized advice to PWE who are still driving by estimating the risk of car accidents.

Facilitating ethical, legal, and professional deliberations to resolve dilemmas in daily healthcare practice: A case of driver with breakthrough seizures

OBJECTIVE

The present study was conducted among pharmacy students to use an 8-step systematic approach to facilitate discussions, deliberations, and decision-making on what to do when facing a dilemma of a patient with epilepsy who drives while having breakthrough seizures.

METHODS

A hypothetical case was developed using the 12-tips for developing dilemma case-based assessments in health education. A mixed method was used in this study. A serial group discussions based on the nominal group technique (NGT) method were applied. A thorough review of the literature and interviews with key experts in the domain (n = 12) were conducted to obtain pertinent data to inform discussions, deliberations, and decision-making. The analytic hierarchy process (AHP) was used to pairwise compare countervailing arguments and alternative courses of action.

RESULTS

In this study, 3 nominal groups were held, and for each 3, discussion rounds were conducted. A total of 27 panelists took part in the nominal groups. Compared with other alternative courses of action, significantly higher weight scores (p-value < 0.001) were given to the course action, "the pharmacist could counsel/educate the patient on the dangers/risks of driving while experiencing breakthrough seizures, inform the patient to refrain from driving in this period, and make a shared decision with the patient to refrain from driving in this period and inform the state authorities".

CONCLUSION

This study demonstrates that the 8-step approach when combined with the AHP can be a handy method in facilitating decision-making while addressing and resolving ethical/legal/professional dilemmas in daily healthcare practice.

Neurologists' attitudes toward driving among persons with epilepsy in China: A pilot electronic survey

PURPOSE AND METHODS

Persons with epilepsy (PWE) remain completely and permanently prohibited from driving in China currently. Previous studies have shown that a considerable proportion of PWE with uncontrolled seizures in China continue to drive motor vehicles. Discrepancy between Chinese policy and driving practices for PWE is potentially concerning. We conducted a preliminary online electronic questionnaire (e-questionnaire) survey among neurologists in China aiming to explore neurologists' attitudes toward the issue of driving among PWE.

RESULTS

A total of 358 neurologists completed the e-questionnaire with a response rate of 75.8%. 50.3% of neurologists stated that they knew the driving restriction law in China. With respect to reporting of cases to relevant driving authorities, 82.4% of neurologists never directly report PWE, and 90.8% consider that it is PWE's responsibility to report themselves. 87.4% of physicians surveyed indicated that the lack of clearly-articulated guidelines is a major impediment to their routine discussions of driving fitness for PWE. Subgroup analysis indicated that 76.2% of epileptologists were of the opinion that persons with well-controlled epilepsy should be allowed to drive versus 56.2% of general neurologists (P < 0.05).

CONCLUSION

Currently, neurologists in China have a low awareness of the legal driving restriction for PWE and have highly varying practices with respect to counseling PWE about driving. According to our preliminary results, a clearly-articulated published national document for medical fitness for driving in China is necessary in order to standardize physicians' practices.

Who is driving and who is prone to have traffic accidents? A systematic review and meta-analysis among people with seizures

INTRODUCTION

Epilepsy influences the ability to drive. We aimed to systematically summarize factors associated with driving, holding a driver's license, and traffic accidents among people with seizures.

MATERIAL AND METHODS

Eight databases were searched (from their inception to 27 June 2018). We included all published observational studies, except for case reports and studies with fewer than 50 participants. Pooled mean differences and pooled risk ratios (pRRs) with corresponding confidence intervals (CIs) were calculated using random effects.

RESULTS

Data were available from 18 studies, reporting a wide range of factors. There were frequent biases associated with cross-sectional study designs, selection bias, poor statistical quality, small samples, and lack of validation of models. The following six variables were consistently associated with driving: male gender (pRR: 1.42; 95% CI: 1.23 to 1.64), being in paid work (pRR: 1.72; 95% CI: 1.46 to 2.03), married (pRR: 1.26; 95% CI: 1.01 to 1.57), older age at seizure onset or diagnosis (pooled mean difference: 4.83; 95% CI: 0.48 to 9.18 years), less frequent seizures (fewer than monthly, pRR: 1.32; 95% CI: 1.12 to 1.56), and taking one or no antiepileptic drug (pRR: 1.34; 95% CI: 1.09 to 1.63). Lower seizure frequency was also protective for avoiding traffic accidents (pRR: 0.26; 95% CI: 0.10 to 0.66).

DISCUSSION

Stable multivariate models to predict driving or traffic accidents among people with seizures have not yet been developed. Current evidence shows that the likelihood of driving is associated with demographic and epilepsy-related factors, while the risk of traffic accidents is associated with seizure frequency.

Prevalence of patients with epilepsy unfit to drive

BACKGROUND:

There is no consensus among medical experts as to whether patients with epilepsy (PWEs) should be permitted to drive. PWEs who have had uncontrolled seizures in the past year are at an increased risk of road traffic accidents, often leading to the destruction of property, injury, or death. Currently, there is no clear policy on whether PWEs can drive in Saudi Arabia. Existing policies attempt to balance the potentially harmful and beneficial aspects of the issue. The purpose of this study was to measure the prevalence of PWEs who are unfit to drive.

MATERIALS AND METHODS:

Data were collected by interviews, a structured validated questionnaire, and a review of the medical records of 140 PWEs, with a response rate of 84%.

RESULTS:

Fifty four percent of PWEs were found unfit to drive. Of the 118 participants, 17.7% did not drive and 97 (82.3%) drove. Of the 21 patients who did not drive, 14 (11.8% of the total sample) never drove and 7 (5.9% of the total sample) stopped driving because of epilepsy. Of the 104 patients who drove, 45 (43.2% of the total sample) had a history of seizures while they drove. These incidents had resulted in the involvement of 28 patients (26.9% of the total sample) in motor vehicle accidents and 17 (16.3% of the total sample) patients being admitted to the emergency room.

CONCLUSION:

Structured regulation and licensing procedures are necessary for PWEs to drive safely. Regulations in other countries demand that seizures be controlled for 1 year before epileptic patients are allowed unrestricted driving. Such regulations would improve road safety in Saudi Arabia.

Epilepsy in Asia: Disease burden, management barriers, and challenges

This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.

Epilepsy-related concerns among patients with epilepsy in West China

PURPOSE

In the present study, we aimed to investigate patient-derived epilepsy-related concerns among Chinese individuals with epilepsy and the impact of seizure control on patient concerns.

METHODS

All adult patients with epilepsy who had visited the outpatient clinic at West China Hospital between July 2014 and June 2016 were invited to participate in the study. All patients were given a blank sheet of paper and asked to list any concerns they had regarding their disease in order of importance. Demographic and clinical characteristics were also evaluated while regression models were used to examine the impact of seizure control on patient concerns.

RESULTS

A total of 1040 patients reported 2202 concerns across 25 distinct categories. The most frequently listed concerns were worries about seizures (55.4%), maintaining a job (17.4%), and the heritability of epilepsy (16.0%). The legal right to drive was listed by only 3.5% of patients who took the survey while seizure recurrence was described by participants as the most important concern (379, 36.4%). Compared with the group with uncontrolled seizures, the group with controlled seizures reported less frequently about "holding down a job" (odds ratio (OR): 0.333 (0.187-0.591)), "fear of being injured during a seizure" (OR: 0.353 (0.183-0.682)), and "leading a normal life" (OR: 0.452 (0.234-0.871)), but they reported more frequently about "having another seizure" (OR: 2.447 (1.614-3.710)), "problems with medication side effects" (OR: 1.733 (1.148-2.616)), and their "legal right or ability to drive" (OR: 2.360 (1.094-5.092)).

CONCLUSION

Our findings indicated that Chinese adults with epilepsy had various concerns, some of which differed from those observed in Western populations. Concerns about heritability of seizures, marriage, and pregnancy were of greater concern to Chinese patients compared with Western patients while the legal right to drive appeared to be less of a concern to Chinese patients. Patients with controlled seizures may still have many concerns. Chinese physicians should monitor patient concerns even among those whose seizures remain controlled to meet their needs. More time and attention should be given to address these issues in clinical practice in the context of Chinese culture.

Epilepsy, antiepileptic drugs, and serious transport accidents: A nationwide cohort study

OBJECTIVES

To investigate the association between epilepsy and antiepileptic drugs and serious transport accidents requiring emergency care or resulting in death.

METHODS

We identified 29,220 individuals 18 years or older with epilepsy without cerebral palsy or intellectual disability and 267,637 matched controls using Swedish registers. This nationwide cohort was followed from 2006 to 2013 for serious transport accidents. We used Cox regression to analyze the risk of serious transport accidents between individuals with epilepsy and matched controls, and then stratified Cox regression to compare the risk during periods of medication with the risk during nonmedication period within the same individual with epilepsy. We adjusted for civil status, employment, education, living area, psychiatric disorders prior to the start of follow-up, and psychotropic medication.

RESULTS

Compared to matched controls, individuals with epilepsy were at increased risk of serious transport accidents (hazard ratio [HR] 1.37; 95% confidence interval [CI] 1.29-1.46). There were increased risks of pedestrian accidents (HR 2.24, 95% CI 1.69-2.97), bicycle accidents (HR 1.68, 95% CI 1.49-1.89) and car accidents (HR 1.31, 95% CI 1.19-1.44). However, among patients with a diagnosis of epilepsy, use of antiepileptic drugs did not influence the risk of serious transport accidents in population-level comparisons (HR 0.97; 95% CI 0.85-1.11) or within-individual comparisons (HR 0.99; 95% CI 0.69-1.42).

CONCLUSION

Serious transportation accidents were more common in individuals with epilepsy, but this risk was independent of use of antiepileptic drugs.

Disobedience and driving in patients with epilepsy in Greece

OBJECTIVE

Regulations and guidelines regarding driving privileges of patients with epilepsy vary greatly worldwide. The aim of our study was twofold: firstly, to evaluate disobedient drivers in Greece and to elucidate their awareness of the law, emotional responses, and seizure profile and, secondly, to identify determinants of disobedience regarding driving among patients with epilepsy.

METHODS

All consecutive patients with epilepsy who visited the epilepsy outpatient clinic of two tertiary epilepsy centers were invited to participate in the study. One hundred ninety patients met our inclusion criteria.

RESULTS

Fifty-two percent of our study population was aware of the driving restrictions. More than one out of three patients were disobedient (35.8%). Being a male was associated with a 6.07-fold increase in the odds of being disobedient (95% CI: 2.73-13.47, p < 0.001); being employed was associated with a 4.62-fold increase in the odds of being disobedient (95% CI: 2.20-9.68, p < 0.001); and each extra antiepileptic drug (AED) was associated with a decrease in the odds of disobedience by a factor of 0.41 (95% CI: 0.26-0.63, p < 0.001).

CONCLUSION

Male gender, employment, and number of AEDs are important determinants of disobedience regarding driving among patients with epilepsy.